26 EWAP SEPTEMBER 2023 REFRACTIVE time for celebration and to see if they’re happy. For those who aren’t seeing well at day 1, it’s about reassurance so they’re not sitting at home wondering why they’re not seeing great. “For all my patients, I counsel them about the most common things to expect,” Dr. Ling said. “You want to focus on the relevant expectations and not go over every possible thing. The consent can cover everything else.” He said that the common things for LASIK are the potential need for a second treatment, accuracy, residual refractive errors, and common side effects. The same goes for SMILE. “For PRK, I counsel patients that they will need to wear a contact lens for the first week, and the vision will gradually get better,” he said. With ICLs, Dr. Ling said you can expect the patient to be functional starting at day 1 following surgery. Vision dramatically improves with the ICL due to the fact that we’re not touching the cornea, he said. “The cornea is pristine, even immediately after surgery. Almost all my patients are 20/40 or better immediately after ICL surgery. The next day is when they get to 20/20 or 20/15,” he said. Side effects may include glare or halo, and Dr. Ling said most patients will notice these issues, but they generally disappear over the course of the first month. He added that patients should be aware of residual refractive error, and he will also mention possible issues with positioning of the lens or exchanging the ICL for a different size. Dr. Ling finds that patients are most concerned about potential side effects. For patients who had LASIK or SMILE, they are also concerned about quality of vision. If vision is fluctuating, he explains that the tear film is a big part that is recovering after laser vision correction. Artificial tears need to be used frequently, Dr. Ling said. With PRK, this requires a longer period for the vision to stabilize, as the surface of the epithelium needs to heal. Diagnostic tests In terms of diagnostic tools and tests that can be used to help patients after surgery, Dr. Loden said he uses OCT to ensure the patient does not have any CME that needs to be treated. This is generally for the cataract and lensectomy patients, he said. Another postop issue is uncorrected refractive error. It’s the number one cause of complaints and dissatisfaction, whether it’s spherical or cylinder. Dr. Loden said he will put the patient in a trial frame with their best correction and ask how it looks to determine how to best proceed with a touch-up procedure. Dry eye is another common problem post-surgery, Dr. Loden said. It might be necessary to use Placido disc topography. Dr. Loden also likes to use the Visiometrics HD Analyzer to measure objective scatter index. Any of the tear film analyzers are helpful to see whether the patient has dry eye or a poor quality tear film that needs to be addressed, Dr. Loden said. When there is an unexpected refractive error in laser vision correction, Dr. Ling said he checks the Pentacam (Oculus) to make sure the cornea appearance is as expected and there is no ectasia or abnormalities. He also checks patients for dry eye with fluorescein tests to make sure they are using artificial tears frequently enough. Dr. Ling suggested checking the refraction at 1 week and 1 month in order to have a comparison. Patients will see a change from the 1-week refraction, but this gives him a sense of where they are and the types of issues they might be having. He typically waits until 3 months after surgery to decide if the patient will need an enhancement. “For laser vision correction, if any touch-up needs to be done, we will usually know by 4–8 weeks out because the refraction stabilizes around that time,” Dr. Ling said, adding that the range for that enhancement is low, around 1–2%, depending on the type of surgery and how high the prescription is. “The higher the prescription you’re treating with laser vision correction, the higher the chance that there may be a need for enhancement,” he said. With ICL procedures, Dr. Ling said he looks closely at the vault of the ICL. “You can check that at the slit lamp by using a diagonal beam to see the space between the ICL and the natural lens and compare that to corneal thickness,” he said. It’s important to check the vault to ensure that the ICL size is suitable. If you’re not sure about the vault through slit lamp, you can get an anterior segment OCT (Optovue Avanti) and measure the exact vault of the ICL over the crystalline lens. “For ICLs, we’d typically be looking at laser vision correction touch-ups and would figure out at about 1 month what the refraction stabilized at,” Dr. Ling said. “You want to have more than one refraction to base that off of.” If a patient’s vault is too low (if there’s less than 100 microns of space between the lens and ICL), there might be a risk of earlier cataract formation, Dr. Ling said. He usually likes to size up for that patient. If the vault is too high (above 750 microns and you have trouble seeing the trabecular meshwork angle on gonioscopy), he’d want to size down. That would allow the trabecular meshwork angle to open up, so you don’t run the risk of having angle closure, he
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